‘Renaissance era’ diagnosis of scurvy in today’s bariatric population

The BMJ Case Report, “Scurvy – a re-emerging disease with the rising cost of living and number of bariatric surgical procedures”, arose when a man in his early fifties presented to Sir Charles Gairdner Hospital in Western Australia with a painful rash on his legs, haematuria, and anaemia.

Investigations for vasculitis, autoimmune disease, and haematological malignancy were normal, and his symptoms continued to worsen.

Maternal medicine specialist Dr Sivanthi Senaratne reviewed the case and recommended a nutritional screen, informed by similar presentations seen in pregnant women after bariatric surgery. Bariatric surgery has risen sharply in Australia, particularly among women of reproductive age. International data show that almost 60 per cent of women undergoing bariatric surgery are aged 20 to 44 years, and a national survey of Australian antenatal clinicians reported that women of childbearing age now form the largest surgical group.1

Large cohort studies show improved fertility outcomes after surgery, but micronutrient deficiencies remain common after sleeve gastrectomy and gastric bypass. Financial pressures can further limit access to fruit, vegetables, and supplements.2

Further history showed that, because of cost pressures, the patient had stopped taking supplements and was consuming little vitamin C rich food. His vitamin C level was undetectable, and other micronutrients were low. Symptoms began to resolve within 24 hours of high dose ascorbic acid.

Lead author Dr Andrew Dermawan said the convergence of rising bariatric surgery, financial pressures, and a preventable deficiency made the case important to share.

Once the BMJ Group press release embargo lifted, extensive media interest was immediate. More than 100 outlets covered the story, including ABC News, the Guardian, and broadcast features on Sky News, LBC News, and international radio and television networks.

Ranked in the top 5 per cent of all research outputs scored by Altmetric

Widely disseminated, with coverage across more than 100 news outlets, multiple blogs, broadcast media, and social platforms

Cited in international peer reviewed journals, including review literature on vitamin C and dermatological disease

Prompted routine dietitian referral and micronutrient screening for post-bariatric inpatients

Highlighted an emerging risk for patients after bariatric surgery

“Having an unusual case and exposing it to the medical fraternity is important, and I love it that BMJ Case Reports does that. It became a big issue in Australia. I hope this report raises awareness on nutritional deficiencies and encourages clinicians to screen for them in patients with risk factors.”

Dr Andrew Dermawan
General Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia